Clinical profiles and mortality rates are similar for metabolic dysfunction-associated steatotic liver disease and non-alcoholic fatty liver disease
Abstract
Background & aims Recently, the term metabolic dysfunction-associated steatotic liver disease (MASLD) has replaced non-alcoholic fatty liver disease (NAFLD). Concern remains regarding whether the evidence generated under the NAFLD definition can be used for MASLD. We compared the clinical profile and outcomes of NAFLD to MASLD using tertiary care- and population-based data.Methods Comparison data were obtained from our NAFLD database and the National Health and Nutrition Examination Survey (NHANES III). Clinical profiles and non-invasive tests (enhanced liver fibrosis [ELF] score, fibrosis-4 index [FIB-4] and vibration-controlled transient elastography) were compared. Mortality data were obtained from NHANES-National Death Index. All-cause mortality was assessed by Cox proportional hazards regression models and cause-specific mortality by competing risk analysis.Results There were 6,429 patients in the NAFLD database (age: 54 ± 12 years, 42% male, BMI 35.4 ± 8.3, waist circumference 112 ± 17 cm, 52% type 2 diabetes). Average scores for ELF, FIB-4 and liver stiffness were 9.6 ± 1.2, 1.69 ± 1.24,14.0 ± 11.8 kPa, respectively; 99% met MASLD criteria; 95% met MASLD on BMI only. Predictive accuracy of ELF and FIB-4 were identical between MASLD and NAFLD. We included 12,519 eligible participants from NHANES (age 43.00 years, 47.38% male, 22.70% obese, 7.28% type 2 diabetes, 82.51% ≥1 cardiometabolic criteria). Among the NHANES study population, there was excellent concordance between MASLD and NAFLD diagnoses: Cohen's kappa coefficient: 0.968 (95% CI 0.962-0.973) with 5.29% of NAFLD cases not meeting MASLD criteria. After a median follow-up of 22.83 years, there were no mortality differences between MASLD and NAFLD diagnoses (p values ≥0.05).Conclusions NAFLD and MASLD are similar except individuals with MASLD seem to be older with slightly higher mortality risk, likely owing to cardiometabolic risk factors. Clinical profiles and non-invasive test thresholds were also identical. These data provide evidence that NAFLD and MASLD terminologies can be used interchangeably. For the small proportion of patients with NAFLD who do not meet MASLD criteria, further consideration is needed.Impact and implications In June 2023, new terminology (MASLD) was adopted to replace the term NAFLD as a means to better describe what the liver disease is rather than what it is not, as well as to potentially reduce stigma. Given that MASLD requires at least one cardiometabolic risk factor, questions were raised as to whether this change in the definition would nullify the similarities between NAFLD and MASLD and require new evidence to be generated for MASLD. We used our NAFLD database and a US population-based database to show that the vast majority of patients with NAFLD fulfill criteria for MASLD. Non-invasive tests performed similarly in both groups. Mortality risk was slightly higher in those with MASLD, which is attributed to the presence of cardiometabolic risks. These results provide evidence that data generated in the past three decades for NAFLD can be used interchangeably for MASLD.
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Analyses of a large tertiary care NAFLD cohort and the population-based NHANESIII data found a nearly complete overlap between NAFLD and MASLD populations, with 99.8% accordance in the NAFLD cohort, while only 5.3% of individuals with NAFLD in the NHANESIII database did not fulfil the MASLD criteria.
“analyses of a large tertiary care NAFLD cohort and the population-based Nutrition Examination Survey (NHANESIII) data found a nearly complete overlap between NAFLD and MASLD populations, with 99.8% accordance in the NAFLD cohort, while only 5.3% of individuals with NAFLD in the NHANESIII database did not ful fi l the MASLD criteria. 4”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [4]
Several re-examinations from existing cohort studies support that NAFLD-related findings can be fully extrapolated to individuals with MASLD.
“Several re-examinations from existing cohort studies support that NAFLD-related fi ndings can be fully extrapolated to individuals with MASLD.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [4]
Long-term follow-up showed similar mortality rates, with slightly higher mortality in MASLD compared to NAFLD.
“Finally, long-term follow-up showed similar mortality rates, with slightly higher mortality in MASLD compared to NAFLD. 4”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [4]
Clinical characteristics were almost identical, and non-invasive tests showed equal accuracy and cutoffs for both NAFLD and MASLD definitions.
“In addition, clinical characteristics were almost identical, and non-invasive tests showed equal accuracy and cutoffs for both de fi nitions. 4”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [4]
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- Authors
- Younossi, Z. M., Paik, J. M., Stepanova, M., Ong, J., Alqahtani, S., & Henry, L.
- Affiliations
- Inova Health System (US)
- University of the Philippines Manila (PH)
- Johns Hopkins University (US)
- Corresponding author
- Younossi, Zobair M.
- Venue
- Journal of Hepatology
- Publisher
- Elsevier BV
- Published
- 2024-05
- Volume
- 80
- Issue
- 5
- Pages
- 694-701
- ISSN
- 0168-8278 (ISSN-L)
- OpenAlex
- W4391281032
- Cited by
- 321
- References
- 29
- Citations by year
- 2026: 91 · 2025: 132 · 2024: 98
- FWCI
- 97.37
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Hepatology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
- Health Sciences › Medicine › Pathology and Forensic Medicine › Alcohol Consumption and Health Effects
- Keywords
- non-alcoholic fatty liver disease, liver fibrosis, enhanced liver fibrosis test, FIB-4, transient elastography, all-cause mortality, cause-specific mortality, type 2 diabetes, obesity, NHANES, clinical profile, competing risk analysis, liver stiffness
- MeSH terms
- Adult, Aged, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Female, Humans, Male, Metabolic Diseases, Middle Aged, Nutrition Surveys, Carboplatin, Non-alcoholic Fatty Liver Disease
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